InterFaith Works of Central New York

Affirm Dignity

Beth Broadway, Program Director

End Racism, Improve Race Relations, Promote Racial Healing

If you prefer a hard copy of this form, please download the form, complete it and mail it back to:

InterFaith Works, 3049 E. Genesee Street, Syracuse, NY 13224
or fax it to 449-3103.
Please call (315) 449-3552 ext. 119 or e-mail us with questions.

Name:	*	Home Phone:	*
Address:		Work Phone:
City:		Email:	*
State:		Fax:
Zip Code:

Circles meet 6 consequtive weeks once a week for two hours. When 12-15 individuals have requested a time period, you will be contacted regarding the location and your availability. Please check the time that best fits your schedule. If you can meet at more than one time, check all for which you are available. This will increase our ability to place you in a circle quickly.

Morning		Evening
Midday		Other
Afternoon		Specify:
Help! I want to participate but none of these options works for me! Please call.
I have special circumstances which are:

To make the Dialogue Circles succeed, it is important to make them racially and ethnically diverse. It is therefore important for us to know your race and ethnicity. Please answer the following questions.

Race:
Age:
Gender:

InterFaith Works of Central New York - 3049 E. Genesee St. - Syracuse, NY 13224 - Tel: 315.449.3552